“Blindness” to another problem during the COVID-19 pandemic: a clinical case

Clinical summary

A 76-year-old woman had a diagnosis of metastatic colon cancer. After surgery and  chemotherapy, there was only a solitary metastasis  in her right hepatic lobe, close to the capsule. The oncologist decided to treat this metastasis  with radiofrequency.

The Medical Oncologist

I, m going to treat this lady with radiofrequency because she is at the limit for a new surgery.  I, m sure she will be fine soon

The patient

I agree with the treatment, because I trusted my doctor

Clinical evolution

The CT localized the metastases and the radiologist placed the probe inside the tumor. After several minutes the procedure was finished and the patient was transferred to the ward.

An hour later she started with fever(38 degrees  centigrades), chills and shortness of breath. Because at that moment the pandemic of SARS-Cov-2 was very active, the intern evaluated  the symptoms as a high probability for COVID-19 disease. The patient had shortness of breath, even resting, without a thoracic pain . She was referred to a special area settled to receive patients with a high suspicion of COVID-19 disease. At that time it was late afternoon and the nurse collected a nasopharyngeal sample for a PCR (Polymerase chain reaction) of coronavirus. The next morning, eight hours later, the result of the test arrived and it was negative for coronavirus. The doctor tried to find an alternative diagnosis.

Although the patient had a respiratory insufficiency no one before registered a proper lung examination, because of the rush originated for the pandemic. During the physical examination after the arrival of the test, the doctor detected a lack of ventilation in her right lung.

Final Diagnosis

Right pneumothorax after hepatic radiofrequency to treat a solitary metastasis.

The patient

Now I feel better, but I, m afraid because I have been in the COVID area, but, the doctor asked for another PCR and it is negative again.

Comments

The fever and chills were related to the  necrosis of the tumor and the liver around. The shortness of breath was a consequence of the pneumothorax, an adverse event associated sometimes with this procedure due to the proximity of the base of the lung to the liver.

Improvement measures

• After an intervention like this  try to associates an acute event with the procedure
• Think that, even during a pandemic, a patient can have another problem with similar signs and symptoms
• Never forget to do a physical examination, at least orientated to the possible source of the problem.

Author: Lorenzo Alonso, MD

FORO  OSLER